COVID-19 testing clinical policy update, Eff 10/1/2021

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Apple Health (Medicaid) Provider Alert

Attention providers:

What changed? 

Effective for claims with dates of service on and after October 1, 2021, the Health Care Authority (HCA) updated the COVID-19 testing clinical policy as follows:

  • Added the following limits for PCR and antigen tests:
    • 4 PCR tests per month, per client; and
    • 4 antigen tests per month, per client

For additional tests, providers must submit a limitation extension request
to HCA.

  • Added over-the-counter (OTC) COVID testing and billing information for pharmacies.
    • Pharmacies may bill for OTC tests prescribed by a provider with prescriptive authority, using a standing order, or when a pharmacist has a collaborative practice agreement that allows for COVID testing.
    • To bill for the OTC COVID tests, pharmacies must follow the NCPDP standard and use the national drug code (NDC) or universal product code (UPC) found on the package.
    • Pharmacies may not bill for test administration of an OTC COVID test. These tests should be used by the patient in the home setting.